Comprehensive Primary Care

Comprehensive Primary Care (CPC) is a systemic approach in general practice that WA Primary Health Alliance co-designed and developed with GPs.

It is a GP-led, integrated place-based approach that aligns to the principles of the Patient Centred Medical Home (PCMH) model.

The principles that underpin PCMH are universally relevant and fundamental to strong primary care. The model plays a pivotal role in achieving improved health of populations, enhanced patient experiences, healthcare cost reductions and better support for health professionals – also known as the Quadruple Aim.

Quadruple Aim

WA Primary Health Alliance will use the underpinning principles of the PCMH to inform its development of a CPC model for WA general practice.

10 Building blocks of high performing primary care

PCMH is in its early stages of adoption within Australia, however it has made significant inroads in areas such as Boston, USA where the Cambridge Health Alliance (CHA) leads a changing approach to primary care.

The CPC model that WA Primary Health Alliance has adopted is based on the Bodenheimer PCMH Model, a well-documented and researched model, and advocates enhanced patient access to comprehensive, coordinated, evidence-based, interdisciplinary care.

We have begun the the first stage in our CPC journey, partnering with selected local general practices across metropolitan Perth and country WA, to see PCMH principles applied within the Australian context. As part of the project, we have a dedicated support team, working across the involved practices and will facilitate an ongoing education program around the model’s 10 critical building blocks.

Select one of the 10 building blocks below to find out more.

Engaged Leadership

High performing practices have leaders fully engaged in the process of change. Even natural leaders learn the science of how to facilitate organisational transformation. High-performing practice have leadership at all levels of the organisation, medical assistants, receptionists, clinicians, and other staff take on the mantle of changing how they and their colleagues do their work. Some engage patients in leadership roles calling upon them as experts in the health care experience to identify priorities for improvement. Leaders create concrete, measurable goals and objectives, such as, the percentage of our patients with diabetes who have glycated haemoglobin (HbA1c) levels greater than 9% will decrease from 20% to 10% by December 31, 2013.

Monitoring progress towards objectives requires the second building block: data systems that track clinical (eg, cancer screening and diabetes management), operational (continuity of care and access), and patients experience metrics. Performance measures are often drilled down to each clinician and care team and are regularly shared with the entire staff to stimulate and evaluate improvement. Data charts may be displayed in prominent locations on the walls of the practice and performance data are discussed in team meetings.

The patient registration otherwise known as empanelment ‘means linking each patients to a care team and a primary care clinician. Even though empanelment requires constant monitoring, many practices have viewed it as foundational. Empanelment is the bases for the therapeutic relationship that is essential for good primary care. To improve continuity (block 7) and establish a patient-team partnership (block 5) it is desirable that patients and care teams know each other. Empanelment interacts closely with team formation because teams assume responsibility for their patient panel.

Empanelment enables the practice to calculate adjusted panel size, which determines whether each clinician and team has a reasonable balance between patients demand for care and the capacity to provide that care. Demand exceeding capacity impedes prompt access to care (block 8). Empanelment allows practices to adjust the workload among clinicians and teams.

High-performing practices view teams as a necessity for the survival of adult primary care. Clinicians without teams caring for a panel of 2,500 patients would spend 17.4 hours per day providing recommended acute, chronic and preventive care. Yet panel size will inevitably grow as the shortage of adult primary care clinicians worsen. Many exemplar practices have created teams with well-trained nonclinicians who add primary care capacity. Building teams that add capacity is called “sharing the care”.

A problem with large teams is that patients may not identify 1 or 2 team members who know them well. To address this issue, high-performing practices generally organise their teams around teamlets – a stable pairing of a clinician and clinical assistant(s) who work together every day and share responsibility for the health of their panel. Some practices have increased productivity or panel size by having 2 or 3 clinical assistants for each clinician. Often a larger team – perhaps a registered nurse, social worker, pharmacist, and behaviourist – supports several teamlets.

Some high-performing practices introduce side-by-side colocation of clinicians and nonclinician staff in common work areas (called pods), agree on ground rules that establish a respectful culture, perform daily huddles, and write standing orders empowering nonclinician staff to share the care. Practice may increase their panel size by assigning a subpanel of patients with uncomplicated chronic conditions to nurses or pharmacists who manage the chronic condition using standing orders.

An effective partnership recognises the expertise that patients bring to the medical encounter as well as the evidence base and medical judgment of the clinician and team. Patients are not told what to do but are engaged in shared decision making that respects their personal goals. For patients with chronic conditions, health coaching (see block 6) provides a framework for self-management support.

High-performing practices stratify the needs of their patient panels and design team roles to match those needs. Three population-based functions provide major opportunities for sharing the care: panel management, health coaching, and complex care management. Panel management involves a staff member, usually a medical assistant or nurse, periodically checking the practice registry to identify patients who are due for routine services (e.g. mammograms, colorectal cancer screening, and HbA1c, or low-density lipoprotein cholesterol laboratory work). Alternatively, the panel manager can check the health maintenance screen on the electronic medical record before a huddle or medical visit to look for care gaps for these services. Standing orders enable panel managers to address care gaps without involving the clinicians. In some practices, most routine care is completed before the clinician enters the examination room, so that visits can focus on patient concerns, issues requiring the clinician’s level of expertise, treatment options and shared care plans. For patients with chronic conditions, health coaching entails assessing patient’s knowledge and motivation, providing information and skills, and engaging patients in behaviour-changing action plans known to improve outcomes. Diabetes patients working with health coaches, whether medical assistants or other patients with diabetes, may have better outcomes than patients without health coaches. When medical assistants, nurses, health educators, or pharmacists act as health coaches, they usually are given protected time to assume this time-consuming function.

Complex care management has emerged as a way to address patients’ needs that are medically and psychosocially complex, as well as patients who are high utilisers of expensive services. Teams headed by registered nurses or social workers have been shown to improve care and reduce costs for patients needing complex care management. Health coaching and complex care management take considerable time, and small practices can benefit from outside organisations assisting them with these functions.

Continuity of care is associated with improved preventive and chronic care, greater patients and clinician experience, and lower cost. To achieve continuity requires empanelment (block 3 – patient registration), which links each patients to a clinician and team. High-performing practices measure continuity for each clinician and achieve continuity goals of 75% to 85%. Reaching these goals requires the front desk staff to encourage patients to see the clinician to whom they are empanelled.

Access is closely linked to patient satisfaction and is a prominent objective for many practices. Though the science of access is well-developed, practices frequently fail in their efforts to reduce patient waiting. Our experience has been that practices are more successful at improving access in a sustainable way when they first measure and control panel size (block 3) and build capacity-enhanced teams (block 4). Access and continuity may be in tension if patients prefer to see any clinician today than their own clinicians next week. High-performing practices allow patients to decide which takes priority.

This refers to the capacity of a practice to provide most of what patients need. Another pillar – care coordination – is the responsibility of primary care to arrange for services that primary care is unable to provide. When a patients needs go beyond primary care practice’s level of comprehensiveness, care coordination is required with the other members of the medical neighbourhood, such as hospitals, pharmacies, and specialists. In high performing systems, clinicians automatically learn when their patients have been discharged from the hospital, and specialist’s referrals are used to their greatest capacity because diagnostic studies are secured in advance by the primary care clinician. Improving care coordination requires teams because busy clinicians lack the time required to coordinate care for every patient with every health care institution. High-performing practices often include a care coordinator or referral coordinator whose sole responsibility is care coordination.

The crown of the building blocks is the template of the future. Few practices have achieved this ultimate goal: a daily schedule that does not rely on the 15-minute in-person clinician visit but offers patients a variety of e-visits, telephone encounters, group appointments, and visits with other team members. Clinicians would have fewer and longer in-person visits and protected time for e-visits and telephone visits. With a team empowered to share the care, clinicians would be able to assume a new role – clinical leader and mentor of the team. Full implementation of this future template requires payment reform that does not reward primary care simply for in-person clinician visits. Some practices are receiving non-visit-based care coordination and pay-for-performance dollars in addition to fee-for-service reimbursement, payments that begin to support new modes of patient encounters. More transformative is to eliminate fee-for-service payments altogether and pay for primary care on a risk-adjusted comprehensive fee per patient with adjustments for quality and patient experience. If primary care practices can reduce unnecessary emergency department and hospital costs for their patients, these practices could also receive a portion of the cost savings.

Better health,
together

WA Primary Health Alliance acknowledges the Traditional Owners of the country on which we work and live and recognises their continuing connection to land, waters and community. We pay our respect to them and their cultures and to Elders both past and present.